Calculating The Full Cost Of War

Above photo: Megan Kingston, who served as a medic in Iraq, wears an oxygen tube as she listens to a House Veterans’ Affairs Health Subcommittee hearing on potential health effects of burn pit exposure, June 7, 2018, in Washington.

A September 11 Reckoning.

Congress should not nickel-and-dime caring for Iraq and Afghanistan veterans recovering from injuries that would have been fatal in previous conflicts.

The withdrawal of U.S. troops from Afghanistan on the eve of the 20th anniversary of the September 11, 2001, attacks that were used to justify multiple Middle Eastern interventions is a fitting occasion to consider the ultimate cost of military combat.

Thanks to advances in military medicine, soldiers injured in Iraq and Afghanistan have had a much higher survival rate, recovering from wounds that would have been fatal decades earlier in Vietnam. As a result, far more post-9/11 combat veterans carry wounds of war, both visible and invisible, for the rest of their lives.

Many news reports cite the trillions of dollars that have been spent directly by the Department of Defense and related agencies on two simultaneous occupations and other global war on terror operations. But far less attention is paid to the future costs of caring for wounded veterans. A brilliant new study by Linda Bilmes published by the Costs of War Project at Brown University documents the current expenditures and the looming threats to their treatment.

In “The Long-Term Costs of United States Care for Veterans of the Afghanistan and Iraq Wars,” Bilmes, a professor of public policy at Harvard, estimates that total expenditures on health care and other benefits for post-9/11 military personnel will reach $2.5 trillion by 2050. She warns that the United States “risks defaulting on our financial obligations to this generation of veterans,” because Congress and the White House are far better at starting wars than fully funding the care of the men and women who serve in them.

While genuflecting, as always, in the direction of “our veterans,” policymakers in Washington rarely acknowledge the seriousness of veterans’ physical and mental health problems. Vietnam veterans still continue to struggle to get Agent Orange–related illnesses recognized and adequately treated. Sadly, this history is repeating itself with the new cohort of post-9/11 veterans.

The soldiers who served in Iraq and Afghanistan make up only 24 percent of all living veterans, but they comprise more than half of the people who are severely disabled. Bilmes notes that “over 40 percent of those who have served … have already been certified as having a ‘service-connected disability,’ compared to fewer than 25 percent of veterans from World War II, Korea, Vietnam and the first Gulf War.”

As I reported in my book Wounds of War, and as Bilmes confirms, their greater need for services from the Veterans Health Administration (VHA), the health care system run by the Department of Veterans Affairs (VA), is due to “more frequent and longer deployments, higher levels of exposure to combat, higher rates of survival from injuries, higher incidence of serious disability, and more complex medical treatments.”

Up to 3.5 million Iraq, Afghanistan, and Gulf War veterans who served in these conflicts live with countless preventable respiratory illnesses and cancers associated with the infamous burn pits run by the Texas-based private contractor KBR. As former Marine Joseph Hickman documents in The Burn Pits: The Poisoning of America’s Soldiers, these infamous dumps burned human corpses and animal carcasses, asbestos insulation, biohazard materials, cleaning supplies, hydraulic fluids, pesticides, human waste, lithium batteries, computer equipment, tires, trucks, polyvinyl chloride pipes, and many other hazardous materials. Such hazards, which were well known to the Pentagon, violated not only Environmental Protection Agency standards but Department of Defense guidelines as well.

Iraq and Afghanistan veterans also suffer in great numbers from traumatic brain injuries (TBIs) caused by improvised explosive devices (IEDs). In their book Shattered Minds: How the Pentagon Fails Our Troops With Faulty Helmets, investigative reporters Robert H. Bauman and Dina Rasor expose the DOD’s refusal to distribute additional helmet pads to members of the infantry along with other standard gear, despite providing such equipment for special forces troops.

The authors estimate that properly engineered padding could have prevented between 300,000 and 400,000 service members from developing TBIs. Instead, the military undermined a “helmet pad vendor’s effort to provide a quality product to the military,” which forced many soldiers to pay for their own state-of-the-art pads or get help modifying their helmets from a nonprofit group called Operation Helmet.

Another signature wound of war in the post-9/11 era is hearing loss and tinnitus. The Defense Department purchased from 3M, but the company defrauded the government and sold the military defective protective equipment. More than 140,000 veterans are now suing the company.

Post-9/11 wars have had a greater adverse impact on women in uniform than any other previous conflict. Women comprised almost 17 percent of the post-9/11 military. According to a report by the Disabled American Veterans (DAV), women veterans utilizing VA maternity services are three and a half times more likely to suffer from post-traumatic stress disorder (PTSD) and five and a half times more likely to suffer from depression than civilian women. Women veterans also suffer from more mental illness and chronic diseases—arthritis and cancers—than civilian women. Plus, their risk for suicide “exceeds that of civilian women by two and [a] half times,” and older women veterans have higher death rates (what’s referred to in epidemiology as “all-cause mortality”) than their civilian counterparts. When polled by the DAV, “60 percent of women who served thought their time in the military had negatively impacted both their physical and mental health.”

Like their male counterparts, many female veterans also suffer from PTSD. Another threat is military sexual trauma (MST), which includes sexual harassment, physical assaults, and rape. According to the DAV, in 2016, “1 in 23 military women survived sexual assault, 1 in 5 active-duty women reported they experienced sexual harassment or a sexually hostile work environment, and 1 in 4 women veterans reported they suffered sexual trauma while serving in the military. In fiscal year 2017, the military recorded a total 6,769 reports of sexual assault, an increase of nearly 10 percent compared to the 6,172 reports made in 2016.”

Far less visible than either PTSD or MST is a problem that plagues the partners of service members: intimate partner violence. Stacy Bannerman describes this issue in painful detail in her book Homefront 911: How Families of Veterans Are Wounded by Our Wars. Thirty-five percent of female veterans have experienced some form of emotional or physical abuse from a partner.

To deal with this vast array of health care problems, the VA has, as Bilmes explains, “ramped up [its] level of responsiveness throughout the past 20 years.” It has hired “thousands of additional medical and support personnel” and “expand[ed] clinical specialties in areas such as women’s health, traumatic brain injury and post-traumatic stress disorder.” Although women veterans make up only 7 percent of the VA’s patient population, the VA has established women’s health clinics in every major medical center, while in its outpatient clinics, those who care for women have training in women’s health and how to sensitively care for MST survivors.

As a result of these and other initiatives, VA patient satisfaction has increased from 80 percent in 2013 to 90 percent in 2020.

Instead of fully funding and staffing a health care system that has well served veterans—as countless studies document—bipartisan majorities in Congress have steadily undermined the VHA by passing legislation that partially privatizes veterans’ health care delivery. Since 2014, these outsourcing measures have steered hundreds of thousands of VHA patients toward private-sector providers that are more expensive and deliver lower-quality care. If such contracting out continues—and it has already cost taxpayers more than $40 billion—the ultimate price tag for post-9/11 veterans’ health care will be even bigger than Bilmes’s estimates, and their treatment will be less effective. A 2021 study comparing the cost and quality of emergency room care in the private sector to that in the VA documented that private-sector emergency room care was 21 percent more expensive and veterans were twice as likely to die after such a visit. VA care is safer and less costly, the study explains, because it is highly coordinated.

Inexplicably, many members of Congress balk at fully funding and staffing the VA because they insist that the veteran population is declining, which, they believe, means they’ll need less care and less money to pay for it. The experience of generations of veterans should have taught Americans that their service-related conditions worsen as they get older. This helps explain why, despite the fact that the veteran population has declined from 25.3 million in 2001 to 18.5 million in 2020, the U.S. is paying twice as much to care for veterans today than it did two decades ago.

In his second inaugural address at the end of the Civil War, which remains the country’s deadliest conflict, President Abraham Lincoln pledged to care for those who “have borne the battle.” As we try to absorb the lessons of 9/11, one thing is clear. Before the country commits to a new war, Americans need to calculate its true cost—which includes the cost of caring for the veterans who return home after the fighting has ended. Passing the legislation proposed by Rep. Mark Takano (D-CA) and Sen. Jon Tester (D-MT), which would make it easier for the VA to care for veterans with burn pit–related illnesses, would be an important indicator of how Americans intend to care for their newest generation of combatants. There is simply no way to treat veterans’ physical injuries and psychic wounds on the cheap.